Brain And Behavioral Development In

Klinefelter Syndrome

Allan L. Reiss, M.D.

Stanford University
Goals of this talk
■  Understand our current state of knowledge regarding brain,
cognitive-behavioral and social-emotional development in
Klinefelter syndrome
■  Learn current methods for assessing brain structure and
function in Klinefelter syndrome
■  Learn how a “precision medicine” approach could improve
specificity and effectiveness of treatment in Klinefelter syndrome
■  Describe new research at Stanford
■  Q & A 
Pre-Talk (Fun) Pop Quiz – 6 Questions
■  Genetic variations in human beings are very rare …
–  True or False?
■  More boys with Klinefelter syndrome are born every year in the U.S. than
boys with Down syndrome…
–  True or False?
■  Brain imaging research is primarily a technique to “read” people’s minds …
–  True or False?
■  “Precision medicine” allows doctors to provide effective and targeted
treatment based on an individual patient’s genetic, medical and
environmental information …
–  True or False?
Nature Versus Nurture?

Nature Nurture

AND
Is the Human Brain Dimorphic?

■  What do you think? Yes? No?

Cahill et al. Scientific American, 2005

 Klinefelter Syndrome – the Basics
■  Due to an “extra” X chromosome in a male (47XXY)
■  Most common sex chromosome condition
–  (1/500-1000 males)
■  Characteristics can include testicular insufficiency,
tall stature, gynecomastia and impaired
spermatogenesis
–  Often requiring testosterone therapy
■  Increased risk for cognitive-behavioral and social-
emotional features:
–  Language problems
–  Executive function problems and ADHD symptoms
–  Social-emotional problems
–  Depressive symptoms
–  Many associated ”DSM” diagnoses (though of questionable
importance aside from obtaining resources)
Cognitive-Behavioral and Social-
Emotional Issues in KS
■  Relative weaknesses in attention, verbal
memory, inhibition and motor function
compared to typically developing age-matched
boys 4-17 years
■  Higher anxiety and depressive symptoms,
greater social problems compared to typically
developing age-matched pre-pubertal boys
■  More problems with executive function, social-
emotional function and depression compared
to typically developing age-matched pre-
pubertal boys Figure. Reduced executive (BRIEF, BASC2
attention), social (SRS) and emotional (BASC2
■  Speaks to importance of early identification depression) function in boys with KS relative to
and treatment! age-matched TD boys. Lower scores are better.
■  Ross et al. Pediatrics, 2017
Review of Testosterone, Puberty and Adolescence
■  Puberty and adolescence mark a transitional period between childhood and
adulthood of immense behavioral and physical change
■  Although the terms “puberty” and “adolescence” are frequently used
interchangeably, to specialists, puberty refers to a distinct developmental period
within adolescence during which complex neuroendocrine processes culminate in
gonadal maturation.
■  Changes in gonadal hormones (i.e., estrogen, testosterone) occurring during puberty
exert a powerful effect on brain circuits, including circuits underlying cognitive and
emotional function
■  These effects occur via permanent modification to brain structure (e.g., change in
neuronal number, myelination or dendritic branching) – so-called “organizational
effects”, and (b) through temporary modification of brain circuits (e.g., activation of
neural systems that underpin reproductive behaviors in young adulthood) – termed
“activational effects”
 Puberty and Brain Development
■  Until recently, researchers believed that fundamental organizational effects
induced by gonadal hormones occurred only early in life, during perinatal
development. It is now clear that this process continues at puberty, when
gonadal hormones spike for a second time
■  This revised understanding of the brain has sparked a reconceptualization
of puberty as a second “critical period” in brain development
■  Emphasizes the importance of understanding and optimizing pubertal
hormone levels in persons with KS!

Testosterone changes through the lifespan.

Testosterone Replacement Therapy (TRT)
■  Standard treatment for KS consists of testosterone replacement
therapy (TRT) beginning at or around puberty, to correct testicular
insufficiency and promote the development of age-appropriate
secondary sexual characteristics
–  In actual clinical settings, much variation in whether to treat as well of timing of TRT
■  There is little information as to whether TRT improves cognitive-
behavioral or social-emotional outcomes in KS when individuals
are treated in the peri-pubertal period over time
■  Recent information suggests low doses of androgen in young, pre-
pubertal children with KS (4-12 years) may improve some outcomes
–  Ross et al., J Pediatrics 2017 (cognitive-behavioral – visuo-motor, social-emotional)
–  Davis et al., J Pediatrics 2017 (cardiometabolic – reduced % body fat, but ± lipids)
Other Things to Know About Testosterone
■  Several small studies suggest that TRT has a beneficial effect on
mood and self-esteem in hypogonadal men (including KS)
■  Testosterone may “protect” against or even treat depression
■  Testosterone (androgen) receptors are found throughout the brain, but
particularly in regions underlying sexual behavior, emotion processing
and learning/memory (e.g., hypothalamus, amygdala, hippocampus,
cortex)
–  Effects may be different depending on developmental period (adult vs childhood)
■  Testosterone levels can be measured in the blood (and maybe saliva)
–  Associated with variation in brain circuits underlying cognitive-behavioral and social-
emotional function in typical adolescent development
Importance of Brain Imaging in KS Research
Structural Imaging – Snapshot of Anatomy
Diffusion Weighted Imaging – Snapshot of
Wiring/Connectivity
Functional Imaging (fMRI)
Another Interesting Imaging Modality – fNIRS
Brain Differences in KS at Baseline
And In Response To Testosterone
 Brain Imaging Results - Summary
■  Smaller volume of the amygdala
–  Involved in processing faces, emotions, social cues
■  Smaller volume of hippocampus
–  Involved in learning and memory
■  Smaller volume of insular cortex
–  Involved in interoception, theory of mind
■  Larger volume of sensorimotor and
posterior cortical regions
–  Related to developmental compensation and
relative strengths in visual-spatial ability?
■  Papers
–  Patwardhan et al. Amer J Med Genet, 2002
–  Hong et al. J Neuroscience, 2014
 80
Retrospective Look at

Temporal lobe volume (cm3)

Testosterone Effects 70
in Adults with KS
■  20 subjects, 10 with KS
■  5 in KS group received testosterone 60
■  Patwadhan et al., Neurology 2000

50

40
Low Dose Oxandrolone Affects Hippocampal
Volume in Pre-pubertal Boys with KS

■  Foland-Ross et al., Psychoneuroendocrinology, 2019

How Can We Learn More About Hormonal
and Environmental Influences in KS?
■  Very little data available about the effect of hormone intervention in KS
other than those studies cited earlier
■  There are no studies showing effects of testosterone on pubertal
development in KS over time (i.e., longitudinal)
■  It is clear that the discussion of “critical developmental windows” as
related to testosterone effects of the brain is highly relevant to KS
outcome
■  These “windows” may coincide with the brain’s “readiness” to be
exposed to sex steroid hormones that facilitate the development of
optimal brain structure, connectivity and function
■  Therefore, new research on timing and duration of hormone intervention
over time is critical for understanding pathways to better outcome
And Don’t Forget Environmental Effects!
■  All influences (leading to individual differences) other than
genetic or hormonal factors

–  Parenting –  Socioeconomic status

–  Family Environment –  Life events
–  Education –  Prenatal events
–  Peer group –  Illness
–  Therapy –  Nutrition

■  No studies in KS on this topic either!

Building a More Complete Model of Brain
and Behavioral Development in KS
Prenatal
Development
47XXY Environment
Early
Development

Hormonal
Alterations
Pubertal Adult
Development Outcome
Precision Medicine Approach to KS: A
New NICHD-funded Study at Stanford
■  There are huge gaps in our understanding of the neural effects of
testosterone supplementation on adolescents with KS
■  The goal of the new project is to clarify the role of TRT on pubertal brain
development and function and to test whether initiating this treatment in
peri-pubertal males leads to improvements in executive and social-
emotional functioning
–  What changes/improves, what does not change/improve
–  Does timing of TRT matter with respect to age or pubertal level make a difference
–  What cognitive-behavioral characteristics remain problematic after TRT – and how do we
address these with additional interventions!
■  Overarching goal to generate research findings that will lead to new,
disorder-specific treatment approaches and improved clinical outcomes
Study to Investigate the Effects of
Testosterone on Brain and Behavior in KS
■  Naturalistic (accelerated) longitudinal study of 60 boys with
KS and 60 age-matched boys with typical development 9-13
years of age at baseline
■  Will follow for up to 4 annual time points at either Stanford or
Jefferson/Nemours (east coast families)
■  Comprehensive cognitive-behavioral, social-emotional
assessments
■  Brain imaging (structure, connectivity, function)
■  Hormone levels and assessment of puberty by pediatric
endocrinology
■  First-of-its-kind study will address important knowledge gaps Figure. Schematic of hypothesized
effects (100 in this example indicates
■  Please contact our study staff at average age-normed scores).
–  650-497-6525
–  klinefeltersyndrome@stanford.edu
http://med.stanford.edu/klinefelterstudy.html
Particular thanks to……
■  Families who HAVE participated in our studies
■  Families who WILL participate in our studies in the future
■  National Institute of Child Health and Human Development
■  Vanessa Alshuler
■  Lara Foland-Ross
■  Judith Ross
■  Tandy Aye
■  David Hong
■  Research staff of the Center for Interdisciplinary Brain Sciences Center at
Stanford